On This Day … 06 April

People (Births)

Tanya Byron

Tanya Byron (born 06 April 1967) is a British psychologist, writer, and media personality, best known for her work as a child therapist on television shows Little Angels and The House of Tiny Tearaways. She also co-created the BBC Two sitcom The Life and Times of Vivienne Vyle with Jennifer Saunders, and still contributes articles to various newspapers.

In 2008, she became Professor of the Public Understanding of Science at Edge Hill University and is the first and current Chancellor of the same institution.

Early Life

When Byron was 15 years old, her German-born paternal grandmother was murdered by being battered to death by a woman who abused illicit drugs. Her grandmother knew the woman, who was in pursuit of money. Byron was perplexed by this cruelty, and at about that time she began to try to understand how anyone could do such a terrible thing and began to be interested in psychology.

Education

Byron was educated at North London Collegiate School, University of York (BSc Psychology, 1989), University College London (MSc Clinical Psychology, 1992), and University of Surrey (PhD, 1995). Her PhD thesis was entitled “The evaluation of an outpatient treatment programme for stimulant drug misuse”, and was completed at University College Hospital.

Career

Prior to training in Clinical Psychology, Byron worked as a researcher on the BBC’s Video Diaries documentary series. Once she qualified, Byron worked in the NHS for 18 years in a number of public health areas such as drug addiction, STDs, and mental disorders.

In 2005, Byron was featured on French and Saunders’ Christmas Special as herself, who came in to sort out Dawn and Jennifer’s childish behaviour on the show. Subsequently, she co-wrote the series The Life and Times of Vivienne Vyle with Jennifer Saunders. Byron has also co-authored a book on parenting based on the Little Angels show and two other books on child development and parenting, as well as writing weekly articles for The Times and contributing to several women’s magazines. She has also worked with the Home Office on the current changes to the Homicide Act as it relates to children and young people, and she also works with the National Family and Parenting Institute advising government and ministers on related policy.

In September 2007, it was announced that she would head an independent review in England – supported by the Department for Children, Schools, and Families, as well as the Department for Culture, Media, and Sport – into the potentially harmful effects of both the Internet and video games on children. This was published in March 2008 as “Safer Children in a Digital World”, but is commonly called the Byron Review.

In April 2008, Byron fronted a four-part show called Am I Normal? exploring the boundaries of acceptable behaviour.

In May 2008, she was elected as the first Chancellor of Edge Hill University, in Lancashire and installed at a ceremony in December 2008.[10] Edge Hill University also appointed her to the post of Professor of the Public Understanding of Science, and she delivered her inaugural lecture, “The Trouble With Kids”, in March the following year.

In 2009, Byron was awarded an honorary doctorate by the University of York.

Byron is the patron of Prospex, a charity which works with young people in North London. She is also a partner in a media company, Doris Partnership.

She has published The Skeleton Cupboard: The Making of a Clinical Psychologist in 2015.

Book: Life as a Clinical Psychologist: What is it Really Like?

Book Title:

Life as a Clinical Psychologist: What is it Really Like?

Author(s): Paul Jenkins.

Year: 2020.

Edition: First (1st).

Publisher: Critical Publishing.

Type(s): Paperback and Kindle.

Synopsis:

Considering a career as a Clinical Psychologist? This book is an ideal, jargon-free introduction for those wishing to find out more about working in this demanding but rewarding mental health profession.

An accessible text that invites you to think critically about whether becoming a Clinical Psychologist is right for you, questioning and challenging your views and providing an honest perspective of life as a clinical psychologist.

Written from personal experience of over 10 years working in applied psychology, with a unique knowledge of the practice, theory, and application of Clinical Psychology, Paul Jenkins provides a first-hand perspective, blending anecdotes with factual advice on the clinical academic culture. It is also packed with case studies which highlight a range of different career pathways (including in other mental health fields) and includes coverage of post-qualification life to gives the reader a sense of the career you can have after training.

What is Behaviour Therapy?

Introduction

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology.

It looks at specific, learned behaviours and how the environment, or other people’s mental states, influences those behaviours, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person’s psychological problems.

Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy, while cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling.

Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles.

Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles.

A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was felt to be weak.

Brief History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behaviour or Learning makes frequent use of the term “modifying behaviour”. Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term “behaviour therapy” was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner’s group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner’s student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing programme called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy’s enduring commitment to the principles of behavioural therapy and biofeedback.

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy (CBT). In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical Basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviours.

Contingency management programmes are a direct product of research from operant conditioning.

Current Forms

Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behaviour analysis. Behavioural psychotherapy has become increasingly contextual in recent years. Behavioural psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualisations.

Functional Analytic Psychotherapy

One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client’s problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client’s progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person’s answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a persons behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment “person variables” are also considered. These “person variables” come from a person’s social learning history and they affect the way in which the environment affects that person’s behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions:

  1. What are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour; and
  2. What type of behaviour therapy or technique that can help the individual improve most effectively.

The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical Applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitisation, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitisation is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitisation is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitisation it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the “model person” as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures:

  1. The procedures are used to decrease the likelihood of the frequency of a certain behaviour; and
  2. Procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them.

The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward.

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis:

  • First behaviour analysis is focused mainly on overt behaviours in an applied setting.
    • Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.
  • Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects.
    • The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated.
  • A third characteristic is that it focuses on what the environment does to cause significant behaviour changes.
  • Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programmes have generally lost favour.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life’s tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won’t expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In Rehabilitation

Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts.

Treatment of Mental Disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitisation has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitisation does not occur over night, there is a process of treatment. Desensitisation is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modelling has been used in dealing with fears and phobias. Modelling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations as well as alcohol use disorder.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn’t focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment Outcomes

Systematic desensitisation has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitisation is an effective technique that can be applied to a number of problems that a person may have.

When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitisation, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment.

While undergoing exposure therapy, a person typically needs five sessions to assess the treatment’s effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions.

Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT, therapists are still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results.

For those with suicidal ideation, treatment depends on how severe the person’s depression and sense of hopelessness is. If these things are severe, the person’s response to completing small steps will not be of importance to them, because they don’t consider the success an accomplishment. Generally, in those not suffering from severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

Third Generation

The third-generation behaviour therapy movement has been called clinical behaviour analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP), behavioural activation (BA), dialectical behavioural therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. Other authors object to the term “third generation” or “third wave” and incorporate many of the “third wave” therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1969) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple’s relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Organisations

Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association’s Division 25 is the division for behaviour analysis. The Association for Contextual Behaviour Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association’s division 25 – Behaviour analysis. APA offers a diploma in behavioural psychology.

The Association for Behavioural and Cognitive Therapies (formerly the Association for the Advancement of Behaviour Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioural an Cognitive Therapies has a special interest group on addictions.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Training

Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy.

Methods

  • Behaviour management.
  • Behaviour modification.
  • Clinical behaviour analysis.
  • Contingency management.
  • Covert conditioning.
  • Decoupling.
  • Exposure and response prevention.
  • Flooding.
  • Habit reversal training.
  • Matching law.
  • Modelling.
  • Observational learning.
  • Operant conditioning.
  • Professional practice of behaviour analysis.
  • Respondent conditioning.
  • Stimulus control.
  • Systematic desensitisation.

Reference

Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. New York: Meredith Corporation.

What is Health Psychology?

Introduction

Health psychology is the study of psychological and behavioral processes in health, illness, and healthcare.

It is concerned with understanding how psychological, behavioural, and cultural factors contribute to physical health and illness. Psychological factors can affect health directly. For example, chronically occurring environmental stressors affecting the hypothalamic-pituitary-adrenal axis, cumulatively, can harm health. Behavioural factors can also affect a person’s health. For example, certain behaviours can, over time, harm (smoking or consuming excessive amounts of alcohol) or enhance health (engaging in exercise). Health psychologists take a biopsychosocial approach. In other words, health psychologists understand health to be the product not only of biological processes (e.g. a virus, tumour, etc.) but also of psychological (e.g. thoughts and beliefs), behavioural (e.g. habits), and social processes (e.g. socioeconomic status and ethnicity).

By understanding psychological factors that influence health, and constructively applying that knowledge, health psychologists can improve health by working directly with individual patients or indirectly in large-scale public health programs. In addition, health psychologists can help train other healthcare professionals (e.g. physicians and nurses) to apply the knowledge the discipline has generated, when treating patients. Health psychologists work in a variety of settings: alongside other medical professionals in hospitals and clinics, in public health departments working on large-scale behaviour change and health promotion programs, and in universities and medical schools where they teach and conduct research.

Although its early beginnings can be traced to the field of clinical psychology, four different divisions within health psychology and one related field, occupational health psychology (OHP), have developed over time. The four divisions include clinical health psychology, public health psychology, community health psychology, and critical health psychology Professional organisations for the field of health psychology include Division 38 of the American Psychological Association (APA), the Division of Health Psychology of the British Psychological Society (BPS), the European Health Psychology Society, and the College of Health Psychologists of the Australian Psychological Society (APS). Advanced credentialing in the US as a clinical health psychologist is provided through the American Board of Professional Psychology.

Overview

Recent advances in psychological, medical, and physiological research have led to a new way of thinking about health and illness. This conceptualisation, which has been labelled the biopsychosocial model, views health and illness as the product of a combination of factors including biological characteristics (e.g. genetic predisposition), behavioural factors (e.g. lifestyle, stress, health beliefs), and social conditions (e.g. cultural influences, family relationships, social support).

Psychologists who strive to understand how biological, behavioural, and social factors influence health and illness are called health psychologists. Health psychologists use their knowledge of psychology and health to promote general well-being and understand physical illness. They are specially trained to help people deal with the psychological and emotional aspects of health and illness. Health psychologists work with many different health care professionals (e.g. physicians, dentists, nurses, physician’s assistants, dietitians, social workers, pharmacists, physical and occupational therapists, and chaplains) to conduct research and provide clinical assessments and treatment services. Many health psychologists focus on prevention research and interventions designed to promote healthier lifestyles and try to find ways to encourage people to improve their health. For example, they may help people to lose weight or stop smoking. Health psychologists also use their skills to try to improve the healthcare system. For example, they may advise doctors about better ways to communicate with their patients. Health psychologists work in many different settings including the UK’s National Health Service (NHS), private practice, universities, communities, schools and organisations. While many health psychologists provide clinical services as part of their duties, others function in non-clinical roles, primarily involving teaching and research. Leading journals include Health Psychology, the Journal of Health Psychology, the British Journal of Health Psychology, and Applied Psychology: Health and Well-Being. Health psychologists can work with people on a one-to-one basis, in groups, as a family, or at a larger population level.

Clinical Health Psychology (ClHP)

ClHP is the application of scientific knowledge, derived from the field of health psychology, to clinical questions that may arise across the spectrum of health care. ClHP is one of the specialty practice areas for clinical psychologists. It is also a major contributor to the prevention-focused field of behavioural health and the treatment-oriented field of behavioural medicine. Clinical practice includes education, the techniques of behaviour change, and psychotherapy. In some countries, a clinical health psychologist, with additional training, can become a medical psychologist and, thereby, obtain prescription privileges.

Public Health Psychology (PHP)

PHP is population oriented. A major aim of PHP is to investigate potential causal links between psychosocial factors and health at the population level. Public health psychologists present research results to educators, policy makers, and health care providers in order to promote better public health. PHP is allied to other public health disciplines including epidemiology, nutrition, genetics and biostatistics. Some PHP interventions are targeted toward at-risk population groups (e.g., undereducated, single pregnant women who smoke) and not the population as a whole (e.g. all pregnant women).

Community Health Psychology (CoHP)

CoHP investigates community factors that contribute to the health and well-being of individuals who live in communities. CoHP also develops community-level interventions that are designed to combat disease and promote physical and mental health. The community often serves as the level of analysis, and is frequently sought as a partner in health-related interventions.

Critical Health Psychology (CrHP)

CrHP is concerned with the distribution of power and the impact of power differentials on health experience and behaviour, health care systems, and health policy. CrHP prioritises social justice and the universal right to health for people of all races, genders, ages, and socioeconomic positions. A major concern is health inequalities. The critical health psychologist is an agent of change, not simply an analyst or cataloguer. A leading organisation in this area is the International Society of Critical Health Psychology.

Health psychology, like other areas of applied psychology, is both a theoretical and applied field. Health psychologists employ diverse research methods. These methods include controlled randomised experiments, quasi-experiments, longitudinal studies, time-series designs, cross-sectional studies, case-control studies, qualitative research as well as action research. Health psychologists study a broad range of health phenomena including cardiovascular disease, (cardiac psychology), smoking habits, the relation of religious beliefs to health, alcohol use, social support, living conditions, emotional state, social class, and more. Some health psychologists treat individuals with sleep problems, headaches, alcohol problems, etc. Other health psychologists work to empower community members by helping community members gain control over their health and improve quality of life of entire communities.

Occupational Health Psychology

Pickren and Degni and Sanderson observed that in Europe and North America occupational health psychology (OHP) emerged as a specialty with its own organisations. The authors noted that OHP owes some of that emergence to health psychology as well as other disciplines (e.g. industrial/organisational psychology, occupational medicine). Sanderson underlined examples in which OHP aligns with health psychology, including Adkins’s research. Adkins documented the application of behavioural principles to improve working conditions, mitigate job stress, and improve worker health in a complex organisation.

Origins and Development

Health psychology developed in different forms in different societies. Psychological factors in health had been studied since the early 20th century by disciplines such as psychosomatic medicine and later behavioural medicine, but these were primarily branches of medicine, not psychology.

United States In 1969, William Schofield prepared a report for the APA entitled The Role of Psychology in the Delivery of Health Services. While there were exceptions, he found that the psychological research of the time frequently regarded mental health and physical health as separate, and devoted very little attention to psychology’s impact upon physical health. One of the few psychologists working in this area at the time, Schofield proposed new forms of education and training for future psychologists. The APA, responding to his proposal, in 1973 established a task force to consider how psychologists could:

  • Help people to manage their health-related behaviours;
  • Help patients manage their physical health problems; and
  • Train healthcare staff to work more effectively with patients.

Health psychology began to emerge as a distinct discipline of psychology in the United States in the 1970s. In the mid-20th century there was a growing understanding in medicine of the effect of behaviour on health. For example, the Alameda County Study, which began in the 1960s, showed that people who ate regular meals (e.g. breakfast), maintained a healthy weight, received adequate sleep, did not smoke, drank little alcohol, and exercised regularly were in better health and lived longer. In addition, psychologists and other scientists were discovering relationships between psychological processes and physiological ones. These discoveries include a better understanding of the impact of psychosocial stress on the cardiovascular and immune systems, and the early finding that the functioning of the immune system could be altered by learning.

Led by Joseph Matarazzo, in 1977, APA added a division devoted to health psychology. At the first divisional conference, Matarazzo delivered a speech that played an important role in defining health psychology. He defined the new field in this way, “Health psychology is the aggregate of the specific educational, scientific and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of diagnostic and etiologic correlates of health, illness and related dysfunction, and the analysis and improvement of the healthcare system and health policy formation.” In the 1980s, similar organizations were established elsewhere. In 1986, the BPS established a Division of Health Psychology. The European Health Psychology Society was also established in 1986. Similar organisations were established in other countries, including Australia and Japan. Universities began to develop doctoral level training programmes in health psychology. In the US, post-doctoral level health psychology training programmes were established for individuals who completed a doctoral degree in clinical psychology.

United Kingdom Psychologists have been working in medical settings for many years (in the UK sometimes the field was termed medical psychology). Medical psychology, however, was a relatively small field, primarily aimed at helping patients adjust to illness. The BPS’s reconsideration of the role of the Medical Section prompted the emergence of health psychology as a distinct field. Marie Johnston and John Weinman argued in a letter to the BPS Bulletin that there was a great need for a Health Psychology Section. In December 1986 the section was established at the BPS London Conference, with Marie Johnston as chair. At the Annual BPS Conference in 1993 a review of “Current Trends in Health Psychology” was organized, and a definition of health psychology as “the study of psychological and behavioural processes in health, illness and healthcare” was proposed.

The Health Psychology Section became a Special Group in 1993 and was awarded divisional status within the UK in 1997. The awarding of divisional status meant that the individual training needs and professional practice of health psychologists were recognised, and members were able to obtain chartered status with the BPS. The BPS went on to regulate training and practice in health psychology until the regulation of professional standards and qualifications was taken over by statutory registration with the Health Professions Council in 2010.

A number of relevant trends coincided with the emergence of health psychology, including:

  • Epidemiological evidence linking behaviour and health.
  • The addition of behavioural science to medical school curricula, with courses often taught by psychologists.
  • The training of health professionals in communication skills, with the aim of improving patient satisfaction and adherence to medical treatment.
  • Increasing numbers of interventions based on psychological theory (e.g. behaviour modification).
  • An increased understanding of the interaction between psychological and physiological factors leading to the emergence of psychophysiology and psychoneuroimmunology (PNI).
  • The health domain having become a target of research by social psychologists interested in testing theoretical models linking beliefs, attitudes, and behaviour.

The emergence of AIDS/HIV, and the increase in funding for behavioural research the epidemic provoked.
The emergence of academic /professional bodies to promote research and practice in health psychology was followed by the publication of a series of textbooks which began to lay out the interests of the discipline.

Objectives

Understanding Behavioural and Contextual Factors

Health psychologists conduct research to identify behaviours and experiences that promote health, give rise to illness, and influence the effectiveness of health care. They also recommend ways to improve health care policy. Health psychologists have worked on developing ways to reduce smoking and improve daily nutrition in order to promote health and prevent illness. They have also studied the association between illness and individual characteristics. For example, health psychology has found a relation between the personality characteristics of thrill seeking, impulsiveness, hostility/anger, emotional instability, and depression, on one hand, and high-risk driving, on the other.

Health psychology is also concerned with contextual factors, including economic, cultural, community, social, and lifestyle factors that influence health. Physical addiction impedes smoking cessation. Some research suggests that seductive advertising also contributes to psychological dependency on tobacco, although other research has found no relationship between media exposure and smoking in youth. OHP research indicates that people in jobs that combine little decision latitude with a high psychological workload are at increased risk for cardiovascular disease. Other research reveals a relation between unemployment and elevations in blood pressure. Epidemiologic research documents a relation between social class and cardiovascular disease.

Health psychologists also aim to change health behaviours for the dual purpose of helping people stay healthy and helping patients adhere to disease treatment regimens (also see health action process approach). Health psychologists employ cognitive behavioural therapy and applied behaviour analysis (also see behaviour modification) for that purpose.

Preventing Illness

Health psychologists promote health through behavioural change, as mentioned above; however, they attempt to prevent illness in other ways as well. Health psychologists try to help people to lead a healthy life by developing and running programmes which can help people to make changes in their lives such as stopping smoking, reducing the amount of alcohol they consume, eating more healthily, and exercising regularly. Campaigns informed by health psychology have targeted tobacco use. Those least able to afford tobacco products consume them most. Tobacco provides individuals with a way of controlling aversive emotional states accompanying daily experiences of stress that characterize the lives of deprived and vulnerable individuals. Practitioners emphasize education and effective communication as a part of illness prevention because many people do not recognise, or minimise, the risk of illness present in their lives. Moreover, many individuals are often unable to apply their knowledge of health practices owing to everyday pressures and stresses. A common example of population-based attempts to motivate the smoking public to reduce its dependence on cigarettes is anti-smoking campaigns.

Health psychologists help to promote health and well-being by preventing illness. Some illnesses can be more effectively treated if caught early. Health psychologists have worked to understand why some people do not seek early screenings or immunisations, and have used that knowledge to develop ways to encourage people to have early health checks for illnesses such as cancer and heart disease. Health psychologists are also finding ways to help people to avoid risky behaviours (e.g. engaging in unprotected sex) and encourage health-enhancing behaviours (e.g. regular tooth brushing or hand washing).

Health psychologists also aim at educating health professionals, including physicians and nurses, in communicating effectively with patients in ways that overcome barriers to understanding, remembering, and implementing effective strategies for reducing exposures to risk factors and making health-enhancing behaviour changes.

There is also evidence from OHP that stress-reduction interventions at the workplace can be effective. For example, Kompier and his colleagues have shown that a number of interventions aimed at reducing stress in bus drivers has had beneficial effects for employees and bus companies.

The Effects of Disease

Health psychologists investigate how disease affects individuals’ psychological well-being. An individual who becomes seriously ill or injured faces many different practical stressors. These stressors include problems meeting medical and other bills, problems obtaining proper care when home from the hospital, obstacles to caring for dependents, the experience of having one’s sense of self-reliance compromised, gaining a new, unwanted identity as that of a sick person, and so on. These stressors can lead to depression, reduced self-esteem, etc.

Health psychology also concerns itself with bettering the lives of individuals with terminal illness. When there is little hope of recovery, health psychologist therapists can improve the quality of life of the patient by helping the patient recover at least some of his or her psychological well-being. Health psychologists are also concerned with providing therapeutic services for the bereaved.

Critical Analysis of Health Policy

Critical health psychologists explore how health policy can influence inequities, inequalities and social injustice. These avenues of research expand the scope of health psychology beyond the level of individual health to an examination of the social and economic determinants of health both within and between regions and nations. The individualism of mainstream health psychology has been critiqued and deconstructed by critical health psychologists using qualitative methods that zero in on the health experience.

Conducting Research

Like psychologists in the other main psychology disciplines, health psychologists have advanced knowledge of research methods. Health psychologists apply this knowledge to conduct research on a variety of questions. For example, health psychologists carry out research to answer questions such as:

  • What influences healthy eating?
  • How is stress linked to heart disease?
  • What are the emotional effects of genetic testing?
  • How can we change people’s health behaviour to improve their health?

Teaching and Communication

Health psychologists can also be responsible for training other health professionals on how to deliver interventions to help promote healthy eating, stopping smoking, weight loss, etc. Health psychologists also train other health professionals in communication skills such as how to break bad news or support behaviour change for the purpose of improving adherence to treatment.

Applications

Improving Doctor-Patient Communication

Health psychologists aid the process of communication between physicians and patients during medical consultations. There are many problems in this process, with patients showing a considerable lack of understanding of many medical terms, particularly anatomical terms (e.g. intestines). One area of research on this topic involves “doctor-centred” or “patient-centred” consultations. Doctor-centred consultations are generally directive, with the patient answering questions and playing less of a role in decision-making. Although this style is preferred by elderly people and others, many people dislike the sense of hierarchy or ignorance that it inspires. They prefer patient-centred consultations, which focus on the patient’s needs, involve the doctor listening to the patient completely before making a decision, and involving the patient in the process of choosing treatment and finding a diagnosis.

Improving Adherence to Medical Advice

Health psychologists engage in research and practice aimed at getting people to follow medical advice and adhere to their treatment regimens. Patients often forget to take their pills or consciously opt not to take their prescribed medications because of side effects. Failing to take prescribed medication is costly and wastes millions of usable medicines that could otherwise help other people. Estimated adherence rates are difficult to measure (see below); there is, however, evidence that adherence could be improved by tailoring treatment programs to individuals’ daily lives. Additionally, traditional cognitive-behavioural therapies have been adapted for people suffering from chronic illnesses and comorbid psychological distress to include modules that encourage, support and reinforce adherence to medical advice as part of the larger treatment approach.

Ways of Measuring Adherence

Health psychologists have identified a number of ways of measuring patients’ adherence to medical regimens:

  • Counting the number of pills in the medicine bottle.
  • Using self-reports.
  • Using “Trackcap” bottles, which track the number of times the bottle is opened.

Managing Pain

Health psychology attempts to find treatments to reduce or eliminate pain, as well as understand pain anomalies such as episodic analgesia, causalgia, neuralgia, and phantom limb pain. Although the task of measuring and describing pain has been problematic, the development of the McGill Pain Questionnaire has helped make progress in this area. Treatments for pain involve patient-administered analgesia, acupuncture (found to be effective in reducing pain for osteoarthritis of the knee), biofeedback, and cognitive behaviour therapy.

Health Psychologist Roles

Below are some examples of the types of positions held by health psychologists within applied settings such as the UK’s NHS and private practice.

  • Consultant health psychologist:
    • A consultant health psychologist will take a lead for health psychology within public health, including managing tobacco control and smoking cessation services and providing professional leadership in the management of health trainers.
  • Principal health psychologist:
    • A principal health psychologist could, for example lead the health psychology service within one of the UK’s leading heart and lung hospitals, providing a clinical service to patients and advising all members of the multidisciplinary team.
  • Health psychologist:
    • An example of a health psychologist’s role would be to provide health psychology input to a centre for weight management.
    • Psychological assessment of treatment, development and delivery of a tailored weight management programme, and advising on approaches to improve adherence to health advice and medical treatment.
  • Research psychologist:
    • Research health psychologists carry out health psychology research, for example, exploring the psychological impact of receiving a diagnosis of dementia, or evaluating ways of providing psychological support for people with burn injuries.
    • Research can also be in the area of health promotion, for example investigating the determinants of healthy eating or physical activity or understanding why people misuse substances.
  • Health psychologist in training/assistant health psychologist:
    • As an assistant/in training, a health psychologist will gain experience assessing patients, delivering psychological interventions to change health behaviours, and conducting research, whilst being supervised by a qualified health psychologist.

Training

In the UK, health psychologists are registered by the Health Professions Council (HPC) and have trained to a level to be eligible for full membership of the Division of Health Psychology within the BPS. Registered health psychologists who are chartered with the BPS will have undertaken a minimum of six years of training and will have specialised in health psychology for a minimum of three years. Health psychologists in training must have completed BPS stage 1 training and be registered with the BPS Stage 2 training route or with a BPS-accredited university doctoral health psychology program. Once qualified, health psychologists can work in a range of settings, for example the NHS, universities, schools, private healthcare, and research and charitable organisations. A health psychologist in training might be working within applied settings while working towards registration and chartered status. A health psychologist will have demonstrated competencies in all of the following areas:

  • Professional skills (including implementing ethical and legal standards, communication, and teamwork).
  • Research skills (including designing, conducting, and analysing psychological research in numerous areas).
  • Consultancy skills (including planning and evaluation).
  • Teaching and training skills (including knowledge of designing, delivering, and evaluating large and small scale training programme).
  • Intervention skills (including delivery and evaluation of behaviour change interventions).

All qualified health psychologists must also engage in and record their continuing professional development (CPD) for psychology each year throughout their career.

In Australia, health psychologists are registered by the Psychology Board of Australia. The standard pathway to becoming an endorsed health psychologists involves a minimum of six years training and a two-year registrar programme. Health psychologists must also undertake continuing professional development (CPD) each year.

What is the Practitioner-Scholar Model?

Introduction

The practitioner-scholar model is an advanced educational and operational model that is focused on practical application of scholarly knowledge.

It was initially developed to train clinical psychologists but has since been adapted by other specialty programmes such as business, public health, and law.

Refer to the Scientist-Practitioner Model.

Model

Creation

In 1973, a new clinical psychology training model was proposed at the historic Vail Conference on Professional Training in Psychology in Vail, Colorado – the practitioner-scholar model – providing yet another path of training for those primarily interested in clinical practice.

Prior to this, in 1949, a ground breaking conference was held in Boulder, Colorado, endorsing a model of study for clinicians that to this day has dominated clinical programs at most University based institutions: the scientist-practitioner model, designed to provide a rigorous grounding in research methods and a breadth of exposure to clinical psychology.

Before this, research scientists had dominated the field of psychological work, and this second, new model, known as the ‘Vail’ model, called for more practitioner-oriented course work.

Features

Several features differentiate the practitioner-scholar model from the other two:

  • Training in this model is more strongly focused on clinical practice than either of the other two.
  • Many (but not all) of these training programs grant a Psy.D. degree rather than a Ph.D. or Ed.D.
  • Admissions criteria may place more of an emphasis on personal qualities of the applicants or clinically related work experience.
  • Accepts a much larger number of students than the typical Ph.D. degree.
  • These programs are typically housed in a greater variety of institutional settings than are research scientist or scientist-practitioner programmes.

Like scientist-practitioner training, practitioner-scholar training is characterised by core courses in both basic and applied psychology, supervision during extensive clinical experience, and research consumption. Both require predoctoral internships that are usually full-time appointments in universities, medical centres, community mental health centres, or hospitals.

Book: Clinical Psychology

Book Title:

Clinical Psychology.

Author(s): Timothy J. Trull and Mitchell J. Prinstein.

Year: 2012.

Edition: Eighth (8th).

Publisher: Wadsworth Publishing Co Inc.

Type(s): Hardcover and Paperback.

Synopsis:

In language your students will understand and enjoy reading, Trull/Prinstein’s “The Science And Practice Of Clinical Psychology, 8E, International Edition” offers a concrete and well-rounded introduction to clinical psychology. A highly respected clinician and researcher, Dr. Trull examines the rigorous research training that clinicians receive, along with the empirically supported assessment methods and interventions that clinical psychologists must understand to be successful in the field. This new edition of Trull’s bestselling text covers cutting-edge trends, as well as offers enhanced coverage of culture, gender and diversity, and contemporary issues of health care. Written to inspire students thinking of pursuing careers in the field of clinical psychology, this text is a complete introduction.

What is Clinical Psychology?

Introduction

Clinical psychology is an integration of science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.

The field is generally considered to have begun in 1896 with the opening of the first psychological clinic at the University of Pennsylvania by Lightner Witmer. In the first half of the 20th century, clinical psychology was focused on psychological assessment, with little attention given to treatment. This changed after the 1940s when World War II resulted in the need for a large increase in the number of trained clinicians. Since that time, three main educational models have developed in the USA – the Ph.D. Clinical Science model (heavily focused on research), the Ph.D. science-practitioner model (integrating scientific research and practice), and the Psy.D. practitioner-scholar model (focusing on clinical theory and practice). In the UK and the Republic of Ireland, the Clinical Psychology Doctorate falls between the latter two of these models, whilst in much of mainland Europe, the training is at the masters level and predominantly psychotherapeutic. Clinical psychologists are expert in providing psychotherapy, and generally train within four primary theoretical orientations – psychodynamic, humanistic, cognitive behavioural therapy (CBT), and systems or family therapy.

Brief History

The earliest recorded approaches to assess and treat mental distress were a combination of religious, magical, and/or medical perspectives. Early examples of such physicians included Patañjali, Padmasambhava, Rhazes, Avicenna, and Rumi. In the early 19th century, one approach to study mental conditions and behaviour was using phrenology, the study of personality by examining the shape of the skull. Other popular treatments at that time included the study of the shape of the face (physiognomy) and Mesmer’s treatment for mental conditions using magnets (mesmerism). Spiritualism and Phineas Quimby’s “mental healing” were also popular.

While the scientific community eventually came to reject all of these methods for treating mental illness, academic psychologists also were not concerned with serious forms of mental illness. The study of mental illness was already being done in the developing fields of psychiatry and neurology within the asylum movement. It was not until the end of the 19th century, around the time when Sigmund Freud was first developing his “talking cure” in Vienna, that the first scientific application of clinical psychology began.

Early Clinical Psychology

By the second half of the 1800s, the scientific study of psychology was becoming well established in university laboratories. Although there were a few scattered voices calling for applied psychology, the general field looked down upon this idea and insisted on “pure” science as the only respectable practice. This changed when Lightner Witmer (1867-1956), a past student of Wundt and head of the psychology department at the University of Pennsylvania, agreed to treat a young boy who had trouble with spelling. His successful treatment was soon to lead to Witmer’s opening of the first psychological clinic at Penn in 1896, dedicated to helping children with learning disabilities. Ten years later in 1907, Witmer was to found the first journal of this new field, The Psychological Clinic, where he coined the term “clinical psychology”, defined as “the study of individuals, by observation or experimentation, with the intention of promoting change”. The field was slow to follow Witmer’s example, but by 1914, there were 26 similar clinics in the US.

Even as clinical psychology was growing, working with issues of serious mental distress remained the domain of psychiatrists and neurologists. However, clinical psychologists continued to make inroads into this area due to their increasing skill at psychological assessment. Psychologists’ reputation as assessment experts became solidified during World War I with the development of two intelligence tests, Army Alpha and Army Beta (testing verbal and nonverbal skills, respectively), which could be used with large groups of recruits. Due in large part to the success of these tests, assessment was to become the core discipline of clinical psychology for the next quarter-century, when another war would propel the field into treatment.

Early Professional Organisations

The field began to organise under the name “clinical psychology” in 1917 with the founding of the American Association of Clinical Psychology. This only lasted until 1919, after which the American Psychological Association (founded by G. Stanley Hall in 1892) developed a section on Clinical Psychology, which offered certification until 1927. Growth in the field was slow for the next few years when various unconnected psychological organisations came together as the American Association of Applied Psychology in 1930, which would act as the primary forum for psychologists until after World War II when the APA reorganised. In 1945, the APA created what is now called Division 12, its division of clinical psychology, which remains a leading organisation in the field. Psychological societies and associations in other English-speaking countries developed similar divisions, including in Britain, Canada, Australia, and New Zealand.

World War II and the Integration of Treatment

When World War II broke out, the military once again called upon clinical psychologists. As soldiers began to return from combat, psychologists started to notice symptoms of psychological trauma labelled “shell shock” (eventually to be termed posttraumatic stress disorder) that were best treated as soon as possible. Because physicians (including psychiatrists) were over-extended in treating bodily injuries, psychologists were called to help treat this condition. At the same time, female psychologists (who were excluded from the war effort) formed the National Council of Women Psychologists with the purpose of helping communities deal with the stresses of war and giving young mothers advice on child rearing. After the war, the Veterans Administration (VA) in the US made an enormous investment to set up programmes to train doctoral-level clinical psychologists to help treat the thousands of veterans needing care. As a consequence, the US went from having no formal university programmes in clinical psychology in 1946 to over half of all Ph.D.s in psychology in 1950 being awarded in clinical psychology.

WWII helped bring dramatic changes to clinical psychology, not just in America but internationally as well. Graduate education in psychology began adding psychotherapy to the science and research focus based on the 1947 scientist-practitioner model, known today as the Boulder Model, for Ph.D. programmes in clinical psychology. Clinical psychology in Britain developed much like in the US after WWII, specifically within the context of the National Health Service with qualifications, standards, and salaries managed by the British Psychological Society.

Development of the Doctor of Psychology Degree

By the 1960s, psychotherapy had become embedded within clinical psychology, but for many, the Ph.D. educational model did not offer the necessary training for those interested in practice rather than research. There was a growing argument that said the field of psychology in the US had developed to a degree warranting explicit training in clinical practice. The concept of a practice-oriented degree was debated in 1965 and narrowly gained approval for a pilot programme at the University of Illinois starting in 1968. Several other similar programmes were instituted soon after, and in 1973, at the Vail Conference on Professional Training in Psychology, the practitioner-scholar model of clinical psychology – or Vail Model – resulting in the Doctor of Psychology (Psy.D.) degree was recognised. Although training would continue to include research skills and a scientific understanding of psychology, the intent would be to produce highly trained professionals, similar to programmes in medicine, dentistry, and law. The first programme explicitly based on the Psy.D. model was instituted at Rutgers University. Today, about half of all American graduate students in clinical psychology are enrolled in Psy.D. programmes.

A Changing Profession

Since the 1970s, clinical psychology has continued growing into a robust profession and academic field of study. Although the exact number of practicing clinical psychologists is unknown, it is estimated that between 1974 and 1990, the number in the US grew from 20,000 to 63,000. Clinical psychologists continue to be experts in assessment and psychotherapy while expanding their focus to address issues of gerontology, sports, and the criminal justice system to name a few. One important field is health psychology, the fastest-growing employment setting for clinical psychologists in the past decade. Other major changes include the impact of managed care on mental health care; an increasing realisation of the importance of knowledge relating to multicultural and diverse populations; and emerging privileges to prescribe psychotropic medication.

Professional Practice

Clinical psychologists engage in a wide range of activities. Some focus solely on research into the assessment, treatment, or cause of mental illness and related conditions. Some teach, whether in a medical school or hospital setting, or in an academic department (e.g., psychology department) at an institution of higher education. The majority of clinical psychologists engage in some form of clinical practice, with professional services including psychological assessment, provision of psychotherapy, development and administration of clinical programmes, and forensics (e.g., providing expert testimony in a legal proceeding).

In clinical practice, clinical psychologists may work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organisations, schools, businesses, and non-profit agencies. Clinical psychologists who provide clinical services may also choose to specialise. Some specialisations are codified and credentialed by regulatory agencies within the country of practice. In the United States such specialisations are credentialed by the American Board of Professional Psychology (ABPP).

Training and Certification to Practice

Clinical psychologists study a generalist programme in psychology plus postgraduate training and/or clinical placement and supervision. The length of training differs across the world, ranging from four years plus post-Bachelors supervised practice to a doctorate of three to six years which combines clinical placement. In the US, about half of all clinical psychology graduate students are being trained in Ph.D. programmes – a model that emphasizes research – with the other half in Psy.D. programmes, which has more focus on practice (similar to professional degrees for medicine and law). Both models are accredited by the American Psychological Association and many other English-speaking psychological societies. A smaller number of schools offer accredited programmes in clinical psychology resulting in a Masters degree, which usually take two to three years post-Bachelors.

In the UK, clinical psychologists undertake a Doctor of Clinical Psychology (D.Clin.Psych.), which is a practitioner doctorate with both clinical and research components. This is a three-year full-time salaried programme sponsored by the National Health Service (NHS) and based in universities and the NHS. Entry into these programmes is highly competitive and requires at least a three-year undergraduate degree in psychology plus some form of experience, usually in either the NHS as an Assistant Psychologist or in academia as a Research Assistant. It is not unusual for applicants to apply several times before being accepted onto a training course as only about one-fifth of applicants are accepted each year. These clinical psychology doctoral degrees are accredited by the British Psychological Society and the Health Professions Council (HPC). The HPC is the statutory regulator for practitioner psychologists in the UK. Those who successfully complete clinical psychology doctoral degrees are eligible to apply for registration with the HPC as a clinical psychologist.

The practice of clinical psychology requires a license in the United States, Canada, the United Kingdom, and many other countries. Although each of the US states is somewhat different in terms of requirements and licenses, there are three common elements:

  • Graduation from an accredited school with the appropriate degree.
  • Completion of supervised clinical experience or internship.
  • Passing a written examination and, in some states, an oral examination.

All US state and Canadian province licensing boards are members of the Association of State and Provincial Psychology Boards (ASPPB) which created and maintains the Examination for Professional Practice in Psychology (EPPP). Many states require other examinations in addition to the EPPP, such as a jurisprudence (i.e. mental health law) examination and/or an oral examination. Most states also require a certain number of continuing education credits per year in order to renew a license, which can be obtained through various means, such as taking audited classes and attending approved workshops. Clinical psychologists require the Psychologist license to practice, although licenses can be obtained with a masters-level degree, such as Marriage and Family Therapist (MFT), Licensed Professional Counsellor (LPC), and Licensed Psychological Associate (LPA).

In the UK registration as a clinical psychologist with the Health Professions Council (HPC) is necessary. The HPC is the statutory regulator for practitioner psychologists in the UK. In the UK the following titles are restricted by law “registered psychologist” and “practitioner psychologist”; in addition, the specialist title “clinical psychologist” is also restricted by law.

Assessment

An important area of expertise for many clinical psychologists is psychological assessment, and there are indications that as many as 91% of psychologists engage in this core clinical practice. Such evaluation is usually done in service to gaining insight into and forming hypotheses about psychological or behavioural problems. As such, the results of such assessments are usually used to create generalized impressions (rather than diagnoses) in service to informing treatment planning. Methods include formal testing measures, interviews, reviewing past records, clinical observation, and physical examination.

Measurement Domains

There exist hundreds of various assessment tools, although only a few have been shown to have both high validity (i.e., test actually measures what it claims to measure) and reliability (i.e., consistency). Many psychological assessment measures are restricted for use by those with advanced training in mental health. For instance, Pearson(one of the many companies with rights and protection of psychological assessment tools separates who can administer, interpret, and report on certain tests.) Anybody is able to access Qualification Level A tests. Those who intend to use assessment tools at Qualification Level B must hold a master’s degree in psychology, education, speech language pathology, occupational therapy, social work, counseling, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, and interpretation of clinical assessments. Those with access to Qualification C (highest level) assessment measures must hold a doctorate degree in psychology, education, or a closely related field with formal training in the ethical administration, scoring, and interpretation of clinical assessments related to the intended use of the assessment.

Psychological measures generally fall within one of several categories, including the following:

  • Intelligence & achievement tests:
    • These tests are designed to measure certain specific kinds of cognitive functioning (often referred to as IQ) in comparison to a norming group.
    • These tests, such as the WISC-IV and the WAIS, attempt to measure such traits as general knowledge, verbal skill, memory, attention span, logical reasoning, and visual/spatial perception.
    • Several tests have been shown to predict accurately certain kinds of performance, especially scholastic.
    • Other tests in this category include the WRAML and the WIAT.
  • Personality tests:
    • Tests of personality aim to describe patterns of behaviour, thoughts, and feelings.
    • They generally fall within two categories: objective and projective.
    • Objective measures, such as the MMPI, are based on restricted answers – such as yes/no, true/false, or a rating scale – which allow for the computation of scores that can be compared to a normative group.
    • Projective tests, such as the Rorschach inkblot test, allow for open-ended answers, often based on ambiguous stimuli.
    • Other commonly used personality assessment measures include the PAI and the NEO.
  • Neuropsychological tests:
    • Neuropsychological tests consist of specifically designed tasks used to measure psychological functions known to be linked to a particular brain structure or pathway.
    • They are typically used to assess impairment after an injury or illness known to affect neurocognitive functioning, or when used in research, to contrast neuropsychological abilities across experimental groups.
  • Diagnostic Measurement Tools:
    • Clinical psychologists are able to diagnose psychological disorders and related disorders found in the DSM-5 and ICD-10.
    • Many assessment tests have been developed to complement the clinicians clinical observation and other assessment activities.
    • Some of these include the SCID-IV, the MINI, as well as some specific to certain psychological disorders such as the CAPS-5 for trauma, the ASEBA, and the K-SADS for affective and Schizophrenia in children.
  • Clinical observation:
    • Clinical psychologists are also trained to gather data by observing behaviour.
    • The clinical interview is a vital part of the assessment, even when using other formalised tools, which can employ either a structured or unstructured format.
    • Such assessment looks at certain areas, such as general appearance and behaviour, mood and affects, perception, comprehension, orientation, insight, memory, and content of the communication.
    • One psychiatric example of a formal interview is the mental status examination, which is often used in psychiatry as a screening tool for treatment or further testing.

Diagnostic Impressions

After assessment, clinical psychologists may provide a diagnostic impression. Many countries use the International Statistical Classification of Diseases and Related Health Problems (ICD-10) while the US most often uses the Diagnostic and Statistical Manual of Mental Disorders. Both are nosological systems that largely assume categorical disorders diagnosed through the application of sets of criteria including symptoms and signs.

Several new models are being discussed, including a “dimensional model” based on empirically validated models of human differences (such as the five factor model of personality) and a “psychosocial model”, which would take changing, intersubjective states into greater account. The proponents of these models claim that they would offer greater diagnostic flexibility and clinical utility without depending on the medical concept of illness. However, they also admit that these models are not yet robust enough to gain widespread use, and should continue to be developed.

Clinical psychologists do not tend to diagnose, but rather use formulation – an individualised map of the difficulties that the patient or client faces, encompassing predisposing, precipitating and perpetuating (maintaining) factors.

Clinical vs Mechanical Prediction

Clinical assessment can be characterised as a prediction problem where the purpose of assessment is to make inferences (predictions) about past, present, or future behaviour. For example, many therapy decisions are made on the basis of what a clinician expects will help a patient make therapeutic gains. Once observations have been collected (e.g. psychological test results, diagnostic impressions, clinical history, X-ray, etc.), there are two mutually exclusive ways to combine those sources of information to arrive at a decision, diagnosis, or prediction. One way is to combine the data in an algorithmic, or “mechanical” fashion. Mechanical prediction methods are simply a mode of combination of data to arrive at a decision/prediction of behaviour (e.g. treatment response). The mechanical prediction does not preclude any type of data from being combined; it can incorporate clinical judgments, properly coded, in the algorithm. The defining characteristic is that, once the data to be combined is given, the mechanical approach will make a prediction that is 100% reliable. That is, it will make exactly the same prediction for exactly the same data every time. Clinical prediction, on the other hand, does not guarantee this, as it depends on the decision-making processes of the clinician making the judgment, their current state of mind, and knowledge base.

What has come to be called the “clinical versus statistical prediction” debate was first described in detail in 1954 by Paul Meehl, where he explored the claim that mechanical (formal, algorithmic) methods of data combination could outperform clinical (e.g. subjective, informal, “in the clinician’s head”) methods when such combinations are used to arrive at a prediction of behaviour. Meehl concluded that mechanical modes of combination performed as well or better than clinical modes. Subsequent meta-analyses of studies that directly compare mechanical and clinical predictions have born out Meehl’s 1954 conclusions. A 2009 survey of practicing clinical psychologists found that clinicians almost exclusively use their clinical judgment to make behavioural predictions for their patients, including diagnosis and prognosis.

Intervention

Refer to Psychotherapy.

Psychotherapy involves a formal relationship between professional and client – usually an individual, couple, family, or small group – that employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving.

Clinicians have a wide range of individual interventions to draw from, often guided by their training – for example, a cognitive behavioural therapy (CBT) clinician might use worksheets to record distressing cognitions, a psychoanalyst might encourage free association, while a psychologist trained in Gestalt techniques might focus on immediate interactions between client and therapist. Clinical psychologists generally seek to base their work on research evidence and outcome studies as well as on trained clinical judgment. Although there are literally dozens of recognised therapeutic orientations, their differences can often be categorised on two dimensions: insight vs. action and in-session vs. out-session.

  • Insight: Emphasis is on gaining a greater understanding of the motivations underlying one’s thoughts and feelings (e.g. psychodynamic therapy).
  • Action: Focus is on making changes in how one thinks and acts (e.g. solution focused therapy, cognitive behavioural therapy).
  • In-session: Interventions centre on the here-and-now interaction between client and therapist (e.g. humanistic therapy, Gestalt therapy).
  • Out-session: A large portion of therapeutic work is intended to happen outside of session (e.g. bibliotherapy, rational emotive behaviour therapy).

The methods used are also different in regards to the population being served as well as the context and nature of the problem. Therapy will look very different between, say, a traumatized child, a depressed but high-functioning adult, a group of people recovering from substance dependence, and a ward of the state suffering from terrifying delusions. Other elements that play a critical role in the process of psychotherapy include the environment, culture, age, cognitive functioning, motivation, and duration (i.e. brief or long-term therapy).

Four Main Schools

Many clinical psychologists are integrative or eclectic and draw from the evidence base across different models of therapy in an integrative way, rather than using a single specific model.

In the UK, clinical psychologists have to show competence in at least two models of therapy, including CBT, to gain their doctorate. The British Psychological Society Division of Clinical Psychology has been vocal about the need to follow the evidence base rather than being wedded to a single model of therapy.

In the US, intervention applications and research are dominated in training and practice by essentially four major schools of practice: psychodynamic, humanistic, behavioural/cognitive behavioural, and systems or family therapy.

1. Psychodynamic

The psychodynamic perspective developed out of the psychoanalysis of Sigmund Freud. The core object of psychoanalysis is to make the unconscious conscious – to make the client aware of his or her own primal drives (namely those relating to sex and aggression) and the various defences used to keep them in check. The essential tools of the psychoanalytic process are the use of free association and an examination of the client’s transference towards the therapist, defined as the tendency to take unconscious thoughts or emotions about a significant person (e.g. a parent) and “transfer” them onto another person. Major variations on Freudian psychoanalysis practiced today include self psychology, ego psychology, and object relations theory. These general orientations now fall under the umbrella term psychodynamic psychology, with common themes including examination of transference and defences, an appreciation of the power of the unconscious, and a focus on how early developments in childhood have shaped the client’s current psychological state.

2. Humanistic/Experiential

Humanistic psychology was developed in the 1950s in reaction to both behaviourism and psychoanalysis, largely due to the person-centred therapy of Carl Rogers (often referred to as Rogerian Therapy) and existential psychology developed by Viktor Frankl and Rollo May. Rogers believed that a client needed only three things from a clinician to experience therapeutic improvement – congruence, unconditional positive regard, and empathetic understanding. By using phenomenology, intersubjectivity and first-person categories, the humanistic approach seeks to get a glimpse of the whole person and not just the fragmented parts of the personality. This aspect of holism links up with another common aim of humanistic practice in clinical psychology, which is to seek an integration of the whole person, also called self-actualisation. From 1980, Hans-Werner Gessmann integrated the ideas of humanistic psychology into group psychotherapy as humanistic psychodrama. According to humanistic thinking, each individual person already has inbuilt potentials and resources that might help them to build a stronger personality and self-concept. The mission of the humanistic psychologist is to help the individual employ these resources via the therapeutic relationship.

Emotion focused therapy/Emotionally focused therapy (EFT), not to be confused with Emotional Freedom Techniques, was initially informed by humanistic-phenomenological and Gestalt theories of therapy. “Emotion Focused Therapy can be defined as the practice of therapy informed by an understanding of the role of emotion in psychotherapeutic change. EFT is founded on a close and careful analysis of the meanings and contributions of emotion to human experience and change in psychotherapy. This focus leads therapist and client toward strategies that promotes the awareness, acceptance, expression, utilisation, regulation, and transformation of emotion as well as corrective emotional experience with the therapist. The goals of EFT are strengthening the self, regulating affect, and creating new meaning”. Similarly to some Psychodynamic therapy approaches, EFT pulls heavily from Attachment theory. Pioneers of EFT are Les Greenberg and Sue Johnson. EFT is often used in therapy with individuals, and may be especially useful for couples therapy. Founded in 1998, Dr. Sue Johnson and others lead the International Centre for Excellence in Emotion Focused Therapy (ICEEFT) where clinicians can find EFT training internationally. EFT is also a commonly chosen modality to treat clinically diagnosable trauma.

3. Behavioural and Cognitive Behavioural

Cognitive behavioural therapy (CBT) developed from the combination of cognitive therapy and rational emotive behaviour therapy, both of which grew out of cognitive psychology and behaviourism. CBT is based on the theory that how we think (cognition), how we feel (emotion), and how we act (behaviour) are related and interact together in complex ways. In this perspective, certain dysfunctional ways of interpreting and appraising the world (often through schemas or beliefs) can contribute to emotional distress or result in behavioural problems. The object of many cognitive behavioural therapies is to discover and identify the biased, dysfunctional ways of relating or reacting and through different methodologies help clients transcend these in ways that will lead to increased well-being. There are many techniques used, such as systematic desensitisation, socratic questioning, and keeping a cognition observation log. Modified approaches that fall into the category of CBT have also developed, including dialectic behaviour therapy and mindfulness-based cognitive therapy.

Behaviour therapy is a rich tradition. It is well researched with a strong evidence base. Its roots are in behaviourism. In behaviour therapy, environmental events predict the way we think and feel. Our behaviour sets up conditions for the environment to feedback back on it. Sometimes the feedback leads the behaviour to increase – reinforcement and sometimes the behaviour decreases – punishment. Oftentimes behaviour therapists are called applied behaviour analysts or behavioural health counsellors. They have studied many areas from developmental disabilities to depression and anxiety disorders. In the area of mental health and addictions a recent article looked at APA’s list for well established and promising practices and found a considerable number of them based on the principles of operant and respondent conditioning. Multiple assessment techniques have come from this approach including functional analysis (psychology), which has found a strong focus in the school system. In addition, multiple intervention programmes have come from this tradition including community reinforcement approach for treating addictions, acceptance and commitment therapy, functional analytic psychotherapy, including dialectic behaviour therapy and behavioural activation. In addition, specific techniques such as contingency management and exposure therapy have come from this tradition.

4. Systems or Family Therapy

Systems or family therapy works with couples and families, and emphasizes family relationships as an important factor in psychological health. The central focus tends to be on interpersonal dynamics, especially in terms of how change in one person will affect the entire system. Therapy is therefore conducted with as many significant members of the “system” as possible. Goals can include improving communication, establishing healthy roles, creating alternative narratives, and addressing problematic behaviours.

Other Therapeutic Perspectives

There exist dozens of recognised schools or orientations of psychotherapy – the list below represents a few influential orientations not given above. Although they all have some typical set of techniques practitioners employ, they are generally better known for providing a framework of theory and philosophy that guides a therapist in his or her working with a client.

  • Existential:
    • Existential psychotherapy postulates that people are largely free to choose who we are and how we interpret and interact with the world.
    • It intends to help the client find deeper meaning in life and to accept responsibility for living.
    • As such, it addresses fundamental issues of life, such as death, aloneness, and freedom.
    • The therapist emphasizes the client’s ability to be self-aware, freely make choices in the present, establish personal identity and social relationships, create meaning, and cope with the natural anxiety of living.
  • Gestalt:
    • Gestalt therapy was primarily founded by Fritz Perls in the 1950s.
    • This therapy is perhaps best known for using techniques designed to increase self-awareness, the best-known perhaps being the “empty chair technique.”
    • Such techniques are intended to explore resistance to “authentic contact”, resolve internal conflicts, and help the client complete “unfinished business”.
  • Postmodern:
    • Postmodern psychology says that the experience of reality is a subjective construction built upon language, social context, and history, with no essential truths.
    • Since “mental illness” and “mental health” are not recognised as objective, definable realities, the postmodern psychologist instead sees the goal of therapy strictly as something constructed by the client and therapist.
    • Forms of postmodern psychotherapy include narrative therapy, solution-focused therapy, and coherence therapy.
  • Transpersonal:
    • The transpersonal perspective places a stronger focus on the spiritual facet of human experience.
    • It is not a set of techniques so much as a willingness to help a client explore spirituality and/or transcendent states of consciousness.
    • It also is concerned with helping clients achieve their highest potential.
  • Multiculturalism:
    • Although the theoretical foundations of psychology are rooted in European culture, there is a growing recognition that there exist profound differences between various ethnic and social groups and that systems of psychotherapy need to take those differences into greater consideration.
    • Further, the generations following immigrant migration will have some combination of two or more cultures – with aspects coming from the parents and from the surrounding society – and this process of acculturation can play a strong role in therapy (and might itself be the presenting problem).
    • Culture influences ideas about change, help-seeking, locus of control, authority, and the importance of the individual versus the group, all of which can potentially clash with certain givens in mainstream psychotherapeutic theory and practice.
    • As such, there is a growing movement to integrate knowledge of various cultural groups in order to inform therapeutic practice in a more culturally sensitive and effective way.
  • Feminism:
    • Feminist therapy is an orientation arising from the disparity between the origin of most psychological theories (which have male authors) and the majority of people seeking counselling being female.
    • It focuses on societal, cultural, and political causes and solutions to issues faced in the counselling process.
    • It openly encourages the client to participate in the world in a more social and political way.
  • Positive psychology:
    • Positive psychology is the scientific study of human happiness and well-being, which started to gain momentum in 1998 due to the call of Martin Seligman, then president of the APA.
    • The history of psychology shows that the field has been primarily dedicated to addressing mental illness rather than mental wellness.
    • Applied positive psychology’s main focus, therefore, is to increase one’s positive experience of life and ability to flourish by promoting such things as optimism about the future, a sense of flow in the present, and personal traits like courage, perseverance, and altruism.
    • There is now preliminary empirical evidence to show that by promoting Seligman’s three components of happiness – positive emotion (the pleasant life), engagement (the engaged life), and meaning (the meaningful life) – positive therapy can decrease clinical depression.

Community psychology approaches are often used for psychological prevention of harm and clinical intervention.

Integration

In the last couple of decades, there has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of cultural, gender, spiritual, and sexual-orientation issues. Clinical psychologists are beginning to look at the various strengths and weaknesses of each orientation while also working with related fields, such as neuroscience, behavioural genetics, evolutionary biology, and psychopharmacology. The result is a growing practice of eclecticism, with psychologists learning various systems and the most efficacious methods of therapy with the intent to provide the best solution for any given problem.

Professional Ethics

The field of clinical psychology in most countries is strongly regulated by a code of ethics. In the US, professional ethics are largely defined by the APA Code of Conduct, which is often used by states to define licensing requirements. The APA Code generally sets a higher standard than that which is required by law as it is designed to guide responsible behaviour, the protection of clients, and the improvement of individuals, organisations, and society. The Code is applicable to all psychologists in both research and applied fields.

The APA Code is based on five principles: Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and Respect for People’s Rights and Dignity. Detailed elements address how to resolve ethical issues, competence, human relations, privacy and confidentiality, advertising, record keeping, fees, training, research, publication, assessment, and therapy.

In the UK the British Psychological Society has published a Code of Conduct and Ethics for clinical psychologists. This has four key areas: Respect, Competence, Responsibility and Integrity. Other European professional organisations have similar codes of conduct and ethics.

Comparison with other Mental Health Professions

Psychiatry

Although clinical psychologists and psychiatrists can be said to share a same fundamental aim – the alleviation of mental distress – their training, outlook, and methodologies are often quite different. Perhaps the most significant difference is that psychiatrists are licensed physicians. As such, psychiatrists often use the medical model to assess psychological problems (i.e. those they treat are seen as patients with an illness) and can use psychotropic medications as a method of addressing the illness although many also employ psychotherapy as well. Psychiatrists are able to conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning.

Clinical psychologists generally do not prescribe medication, although there is a movement for psychologists to have prescribing privileges. These medical privileges require additional training and education. To date, medical psychologists may prescribe psychotropic medications in Guam, Iowa, Idaho, Illinois, New Mexico, Louisiana, the Public Health Service, the Indian Health Service, and the United States Military.

Counselling Psychology

Counselling psychologists undergo the same level of rigor in study and use many of the same interventions and tools as clinical psychologists, including psychotherapy and assessment. Traditionally, counselling psychologists helped people with what might be considered normal or moderate psychological problems – such as the feelings of anxiety or sadness resulting from major life changes or events. However, that distinction has faded over time, and of the counselling psychologists who do not go into academia (which does not involve treatment or diagnosis), the majority of counselling psychologists treat mental illness alongside clinical psychologists. Many counselling psychologists also receive specialised training in career assessment, group therapy, and relationship counselling.

Counselling psychology as a field values multiculturalism and social advocacy, often stimulating research in multicultural issues. There are fewer counselling psychology graduate programmes than those for clinical psychology and they are more often housed in departments of education rather than psychology. Counselling psychologists tend to be more frequently employed in university counselling centres compared to hospitals and private practice for clinical psychologists. However, counselling and clinical psychologists can be employed in a variety of settings, with a large degree of overlap (prisons, colleges, community mental health, non-profits, corporations, private practice, hospitals and Veterans Affairs).

School psychologists are primarily concerned with the academic, social, and emotional well-being of children and adolescents within a scholastic environment. In the UK, they are known as “educational psychologists”. Like clinical (and counselling) psychologists, school psychologists with doctoral degrees are eligible for licensure as health service psychologists, and many work in private practice. Unlike clinical psychologists, they receive much more training in education, child development and behaviour, and the psychology of learning. Common degrees include the Educational Specialist Degree (Ed.S.), Doctor of Philosophy (Ph.D.), and Doctor of Education (Ed.D.).

Traditional job roles for school psychologists employed in school settings have focused mainly on assessment of students to determine their eligibility for special education services in schools, and on consultation with teachers and other school professionals to design and carry out interventions on behalf of students. Other major roles also include offering individual and group therapy with children and their families, designing prevention programs (e.g. for reducing dropout), evaluating school programs, and working with teachers and administrators to help maximise teaching efficacy, both in the classroom and systemically.

Clinical Social Work

Social workers provide a variety of services, generally concerned with social problems, their causes, and their solutions. With specific training, clinical social workers may also provide psychological counselling (in the US and Canada), in addition to more traditional social work. The Masters in Social Work in the US is a two-year, sixty credit programme that includes at least a one-year practicum (two years for clinicians).

Occupational Therapy

Occupational therapy – often abbreviated OT – is the “use of productive or creative activity in the treatment or rehabilitation of physically, cognitively, or emotionally disabled people.” Most commonly, occupational therapists work with people with disabilities to enable them to maximise their skills and abilities. Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the physical, emotional, psychological, sociocultural, cognitive and environmental components of illness and injury. They commonly work alongside clinical psychologists in settings such as inpatient and outpatient mental health, pain management clinics, eating disorder clinics, and child development services. OT’s use support groups, individual counselling sessions, and activity-based approaches to address psychiatric symptoms and maximise functioning in life activities.

Criticisms and Controversies

Clinical psychology is a diverse field and there have been recurring tensions over the degree to which clinical practice should be limited to treatments supported by empirical research. Despite some evidence showing that all the major therapeutic orientations are about of equal effectiveness, there remains much debate about the efficacy of various forms treatment in use in clinical psychology.

It has been reported that clinical psychology has rarely allied itself with client groups and tends to individualise problems to the neglect of wider economic, political and social inequality issues that may not be the responsibility of the client/service user. It has been argued that therapeutic practices are inevitably bound up with power inequalities, which can be used for good and bad. A critical psychology movement has argued that clinical psychology, and other professions making up a “psy complex”, often fail to consider or address inequalities and power differences and can play a part in the social and moral control of disadvantage, deviance and unrest.

An October 2009 editorial in the journal Nature suggests that a large number of clinical psychology practitioners in the United States consider scientific evidence to be “less important than their personal – that is, subjective – clinical experience.”

On This Day … 09 December

People (Births)

  • 1926 – Jan Křesadlo, Czech-English psychologist and author (d. 1995).
  • 1972 – Saima Wazed Hossain, Bangladeshi psychologist.

Jan Kresadlo

Václav Jaroslav Karel Pinkava (09 December 1926 to 13 August 1995), better known by his pen name Jan Křesadlo, was a Czech psychologist who was also a prizewinning novelist and poet.

An anti-communist, Pinkava emigrated to Britain with his wife and four children following the 1968 invasion of Czechoslovakia by the Soviet-led armies of the Warsaw pact. He worked as a clinical psychologist until his early retirement in 1982, when he turned to full-time writing. His first novel “Mrchopěvci” (GraveLarks) was published by Josef Škvorecký’s emigre publishing house 68 Publishers, and earned the 1984 Egon Hostovský prize.

He chose his pseudonym (which means firesteel) partly because it contains the uniquely Czech sound ř; in addition, he was fond of creating more pseudonyms such as Jake Rolands (an anagram), J. K. Klement (after his grandfather, for translations into English), Juraj Hron (for his Slovak-Moravian writings), Ferdinand Lučovický z Lučovic a na Suchým dole (for his music), Kamil Troud (for his illustrations), Ἰωάννης Πυρεῖα (for his Astronautilia), and more.

Pinkava was also active in choral music, composing (among others) a Glagolitic Mass. As well, he worked in mathematical logic, discovering the many-valued logic algebra which bears his name.

A polymath and polyglot, Pinkava was fond of setting intense goals for himself, such as translating Jaroslav Seifert’s interwoven sonnet cycle about Prague, ‘A Wreath of Sonnets’. He published a collection of his own poems in seven languages. Perhaps his most staggering achievement is ΑΣΤΡΟΝΑΥΤΙΛΙΑ Hvězdoplavba, a 6575-line science fiction epic poem, an odyssey in classical Homeric Greek, with its parallel hexameter translation into Czech. This was published shortly after his death, in a limited edition. Only his first, prize-winning novel has been published in English translation, as GraveLarks in a bilingual edition in 1999 and in a revised edition in 2015.

He is the father of film director Jan Pinkava who received an Oscar for Geri’s Game in 1998 and also illustrated GraveLarks.

Saima Wazed

Saima Wazed Hossain (born 09 December 1972) is a Bangladeshi autism activist. She is the daughter of Bangladesh’s Prime Minister, Sheikh Hasina. She is a member of the World Health Organisation’s (WHO) 25-member Expert Advisory Panel on mental health. To her family, she is known simply as “Putul”.

Early Life and Education

She was born to Sheikh Hasina, the present Prime Minister of Bangladesh, and M.A. Wazed Miah, a nuclear scientist. Her brother is Sajeeb Wazed Joy. She graduated from Barry University. She is a licensed school psychologist.

Career

She organized the first South Asian conference on Autism in 2011 in Dhaka, Bangladesh. She is the chairperson of National Advisory Committee on Autism and Neurodevelopmental disorders. She campaigned for “Comprehensive and Coordinated Efforts for the Management of Autism Spectrum Disorders” resolution at the World Health Assembly which adopted the resolution, Autism Speaks praised her for spearheading “a truly global push for support for this resolution”.

In November, 2016, Wazed had been elected as chairperson of International Jury Board meeting of UNESCO for Digital Empowerment of Persons with Disabilities.

In April 2017, Wazed has been designated as WHO Champion for Autism” in South-East Asia. In July, 2017 she became the Goodwill Ambassador of the WHO for autism in South-East Asia Region.

Award

In 2016, Wazed has conferred WHO’s South-East Asia Region Award for Excellence in Public Health. In 2017, she has been awarded the International Champion Award for her outstanding contribution to the field of autism. She received a distinguished alumni award from Barry University for her activism.

Book: It’s Not OK to Feel Blue (and other lies)

Book Title:

It’s Not OK to Feel Blue (and other lies): Inspirational people open up about their mental health.

Author(s): Scarlett Curtis.

Year: 2020.

Edition: First (1st).

Publisher: Penguin.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

Everyone has a mental health. So we asked:

What does yours mean to you?

THE RESULT IS EXTRAORDINARY.

Over 60 people have shared their stories. Powerful, funny, moving, this book is here to tell you:

It’s OK.

Book: Life as a Clinical Psychologist

Book Title:

Life as a clinical psychologist: What is it really like?

Author(s): Paul Jenkins.

Year: 2020.

Edition: First (1st).

Publisher: Critical Publishing.

Type(s): Paperback and Kindle.

Synopsis:

Considering a career as a Clinical Psychologist? This book is an ideal, jargon-free introduction for those wishing to find out more about working in this demanding but rewarding mental health profession.

An accessible text that invites you to think critically about whether becoming a Clinical Psychologist is right for you, questioning and challenging your views and providing an honest perspective of life as a clinical psychologist.

Written from personal experience of over 10 years working in applied psychology, with a unique knowledge of the practice, theory, and application of Clinical Psychology, Paul Jenkins provides a first-hand perspective, blending anecdotes with factual advice on the clinical academic culture. It is also packed with case studies which highlight a range of different career pathways (including in other mental health fields) and includes coverage of post-qualification life to gives the reader a sense of the career you can have after training.